Application For Child Care Assistance Dutchess County .
DO NOT WRITE IN SHADED AREAS - COMPLETE ALL QUESTIONS NOT LISTED AS OPTIONALOCFS-6025 (Rev. 05/2019)Page 1NEW YORK STATEOFFICE OF CHILDREN AND FAMILY SERVICESAPPLICATION FOR CHILD CARE ASSISTANCEATTENTION: This application is used to apply ONLY for Category 2 or 3 Child Care Assistance. To apply for Cash Public Assistance or other benefits,including Category 1 Child Care Assistance, you must use the New York State Application for Certain Benefits and Services (LDSS-2921).CASE NAMECASE #REGISTRY #OFFICEUNITWORKERAPP DATE//CASE TYPE:DISTRICT:Services Transaction Type:40New OpenReopenRecert.Disposition:DenialReason CodeWithdrawalSECTION 1. APPLICANT'S INFORMATIONFIRST NAMEM.I.LAST NAME (Please include any ALIASES or MAIDEN names in parentheses.)PHONENUMBER()-STREET ADDRESSAPT NO.CITYSTATEZIP CODEMAILING ADDRESS (IF DIFFERENT FROM ABOVE)APT NO.CITYSTATEZIP CODEFORMER ADDRESS (IN PAST YEAR)OTHER PHONE NUMBERS WHERE YOU CAN BE REACHEDMarital status?SingleMarriedDivorcedPrimary language?EnglishSpanishOther (specify)SeparatedWidowedEmail (optional):SECTION 2. LIST EVERYBODY WHO LIVES WITH YOU, EVEN IF THEY ARE NOT APPLYING WITH YOU. LIST YOURSELF ON THE FIRST LINE.LN1FIRST NameM. I.LAST Name(Please include any ALIASES orMAIDEN names in parentheses)DATE OFBIRTH(MM-DD-YY)SEX(M/F)RELATIONSHIPTO YOUSOCIALSECURITYNUMBER(SSN)OptionalEnter Y (Yes) or N (No) ifHispanic or Latino (Optional)Enter Y (Yes) or N (No)for each /N)FOR EACH CHILD in need of childcare, answer Yes/NoChild is U.S.Citizen/National Does childhave a disor 78* Racial Affiliation Codes: I – Native American or Alaskan Native, A – Asian, B – Black or African American, P – Native Hawaiian or Pacific Islander, W – WhiteYou may use additional pages if you need more room or there is other information that you think we might need.Do bothparentsreside inthe home?
OCFS-6025 (Rev. 05/2019)Page 2SECTION 3. OTHER HOUSEHOLD INFORMATIONDO ANY OF THESE APPLYTO YOU OR YOUR SPOUSE/THEOTHER PARENT IF THEY LIVE INTHE HOME?For each of the following,answer YES or NO:YESNONeed child care to workYESNONeed child care for another reason. Give reason:YESNOHomeless (no fixed, regular, and adequate place to stay at night)YESNOA parent is on active duty (serving full-time) in the U.S. Military.YESNOA parent is a member of a National Guard or Military Reserve unit.YESNOReceiving or applying for Cash Public Assistance through a different applicationYESNOReceiving or applying for other child care funding. Agency Name:YESNOPregnant. Due date://SECTION 4. ABSENT PARENT INFORMATION. List children in need of child care whose parent does not live in the household.Is absent parentNAMES OF CHILDRENABSENT PARENT’S NAME AND ADDRESSavailable to provideUNDER 21care?YesNoYesNoYesNoIf No, give reason.SECTION 5. APPLICANT’S EMPLOYMENT INFORMATIONEMPLOYER’S NAMEWORK PHONE(EMPLOYER’S ADDRESSCITYDoes the job have rotating or variable shifts?HourlyWage: What is atypical oes the job require overtime (O/T)?TUESDAYFROMSTART DATE OF JOB-TOWEDNESDAYFROMTOYESTHURSDAYFROM/ZIP CODETONOFRIDAYFROMSATURDAYTOFROMTOSECTION 6. OTHER EMPLOYMENT INFORMATION. Use this section for an applicant’s second job or a spouse’s/other parent’s job (if they live in the home).Applicant’s jobWhose job information (check one)?Spouse’s jobOther Parent’s jobEMPLOYER’S NAMEWORK PHONE(EMPLOYER’S ADDRESSCITYDoes the job have rotating or variable shifts?HourlyWage: What is atypical workschedule?YESSUNDAYFROMTONOMONDAYFROMTOSTART DATE OF JOB-/STATEDoes the job require overtime /ZIPCODETONOFRIDAYFROMTOSATURDAYFROMTO
OCFS-6025 (Rev. 05/2019)Page 3SECTION 7. INCOME INFORMATIONIndicate if you or anyone who is applying withyou receives money from:YESIncome from work (including wages/salary, overtime,commissions, training programs, tips)NOWHO?GROSSAMOUNTPERIOD (week,month, etc.)GROSSAMOUNTWHO?PERIOD (week,month, etc.)Net Self-Employment IncomeChild Support Payments (received)Alimony/Spousal Support (received)Unemployment Insurance Benefits, Workers’ CompSocial Security Benefits (including SSI)Disability Benefits (NYS, VA, Private)Rental/Boarder/Lodger Income (received)Dividends/Interest - Stocks, Bonds, SavingsPensions/AnnuitiesCash Public Assistance (PA) Grant, Safety NetBenefitsOther (Please specify.)SECTION 8. TRAVEL TIME BETWEEN CHILD CARE PROVIDER AND WORK/EDUCATIONAL/OTHER APPROVED ACTIVITY.DROP-OFFTravel time from the child careprovider to work/activity?Public Transportation?YESNOPICK-UPTravel time from work/activityto the child care provider?Public Transportation?YESNOSECTION 9. CHILD CARE PROVIDER INFORMATIONPROVIDER NAME AND ADDRESSNAMES OF CHILDRENALREADY ENROLLED?YesNoYesNoYesNoSECTION 10. CHILD’S SCHOOL INFORMATION. List all children enrolled in schoolSCHOOL NAME AND ADDRESSNAMES OF CHILDRENATTENDANCE HOURSSTART TIMEEND TIME
OCFS-6025 (Rev. 05/2019)Page 4SECTION 11. NOTICES. READ THE IMPORTANT CERTIFICATIONS AND CONSENTS BELOW.CHANGE REPORTING – I understand that by signing this application form I agree to inform the agency immediately of any change in my needs, income, living arrangement, oraddress to the best of my knowledge or belief. I agree to inform the agency immediately of any change in child care arrangements, including where child care is provided, who isproviding care, provider’s fees, and hours for which child care is needed.PENALTIES – Federal and state laws provide for penalties, including fines, imprisonment, or both if you do not tell the truth when you apply for Child Care Assistance or when you arequestioned about your eligibility, or if you cause someone else not to tell the truth regarding your application or continuing eligibility. Penalties also apply if you conceal or fail to disclosefacts regarding your initial or continuing eligibility for Child Care Assistance; or if you conceal or fail to disclose facts that would affect the right of someone, for whom you have applied,to obtain or continue to receive Child Care Assistance. If you are the authorized representative applying on behalf of someone else, Child Care Assistance must be used for that personand not yourself. It is unlawful to obtain Child Care Assistance by concealing information or providing false information.CITIZENSHIP – By signing this application, I swear and/or affirm that all the children needing Child Care Assistance are United States citizens or nationals, or persons with satisfactoryimmigration status. I understand that this information will only be shared to make decisions about the Child Care Assistance Program, and that the United States Citizenship andImmigration Services may be contacted if more information is needed to verify the children’s status.CONSENT FOR INVESTIGATION – I understand that by signing this application form I agree to cooperate fully with any investigation to verify or confirm the information I have givenor any other investigation in connection with my request for Child Care Assistance. I will provide additional information if it is requested.RESOURCES – I certify that my family resources do not exceed 1,000,000. Resources include, but are not limited to, cash, bank accounts, real estate, stocks, bonds, mutual funds,IRAs, 401(k) accounts, life insurance, trust accounts, annuities, burial funds/spaces.NON-DISCRIMINATION – This application will be considered without regard to race, color, sex, disability, religious creed, national origin or political belief.SECTION 12. CERTIFICATION AND SIGNATURECERTIFICATION: I swear and/or affirm under the penalties of perjury that all of the information I have given or will give to the local department of social services relating to Child CareAssistance is correct. I have read and understand the notices above. I understand and agree to the consents.APPLICANT’S/REPRESENTATIVE’S SIGNATUREDATE SIGNED/X/PRINT NAME:SECOND APPLICANT’S/REPRESENTATIVE’S SIGNATUREDATE SIGNED/X/PRINT NAME:RETURN YOUR APPLICATION TO: THE LOCALDEPARTMENT OF SOCIAL SERVICES (LDSS)OF THE COUNTY THAT YOU LIVE IN.FOR AGENCY USE ONLY:CASE NAMESERVICES TRANS TYPE:ELIGIBILITY DETERMINED BYCASE #New OpenREGISTRY #ReopenDisposition:Recert.DATE/CHILD CARE AUTHORIZATION FROM DATE//L1 CIN:L4 CIN:L7 CIN:L2 CIN:L5 CIN:L8 CIN:L3 CIN:L6 CIN:L9 CIN:RE-USE INDICATORDenialELIGIBILITY APPROVED BYDISTRICT:CASE TYPE: 40Reason CodeCOMMENTS:DATE/WithdrawalDATE//CHILD CARE AUTHORIZATION TO DATE//VERSION #//
NYS Agency-Based Voter Registration FormImportant!YIVOc ecke Y S,ase ceGON PP CON eNO eca se I cIaa eaI askeIf you would like help filling out the voter registration application form,we will help you. The decision whether to seek or accept help is yours.You may fill out the application form in private.e s e ORsee see aaApplying to register or declining to register to vote will not affect theamount of assistance that you will be provided by this agency.cece e aaeess ORaInformación en español: si le interesa obtener este formulario enespañol, llame al 1-800-367-8683e s 格,請電: 1-800-367-8683/Se한국어: 한국어 한국어 양식을 원하시면/으로 전화 하십시오. 1-800-367-8683DaRev. 2/2015যদি আপদি এই ফর্মটি ইংরেজীরে পপে প চাি োহরে 1-800-367-8683িম্বরে পফাি করুিase PraVOTER REGISTRATION APPLICATION (instructions on back)Please print or type in blue or black inkYes, I need an application for an Absentee BallotAre you a U.S. citizen?YES1NOYES2If you answered NO, do not complete this form345610Last NameFirst NameApt. No.SexMNOMiddle InitialAddress where you get your mail (if different than above)7For Board Use OnlyIf you answered NO, do not complete this formunless you will be 18 by the end of the yearAddress where you live (do not give P.O. box)Date of BirthYes, I would like to be an Election Day workerWill you be 18 years old on or before election day?City/Town/VillageZip CodeP.O. Box, Star Route, etc.8FSuffixTelephone (optional)The last year you votedYour address was (give house number, street and city)In county/stateUnder the name (if different from your name now)CountyPost OfficeZip CodeEmail (optional)ID Number (Check the applicable box and provide your number)9New York State DMV numberLast four digits of your Social Security numberI do not have a New York State DMV or Social Security numberPolitical PartyAffidavit: I swear or affirm thatI wish to enroll in a political partyDemocratic partyRepublican partyConservative partyGreen partyWorking Families party11 I am a citizen of the United States. I will have lived in the county, city or village for at least 30 days beforethe election.Independence partyWomen’s Equality partyReform partyOther12 I will meet all requirements to register to vote in New York State. This is my signature or mark on the line below. The above information is true, I understand that if it is not true, I can beconvicted and fined up to 5,000 and/or jailed for up to four years.I do not wish to enroll in a political party/No partySignature or Mark in ink/Date(Optional) Register to donate your organs and tissuesBy signing below, you certify that you are:Last NameFirst NameMiddle InitialSuffixAddressApt NumberBirth DateCity/Town/VillageZip CodeSexMEye Color 18 years of age or older Consent to donate all of your organs and tissues fortransplantation, research, or both; Authorizing the Board of Elections to provide your name andidentifying information to DOH for enrollment in the Registry; And authorizing DOH to allow access to this information to federally regulated organprocurement organizations and NYS-licensed tissue and eye banks and hospitalsupon your death.F/HeightFt.In.SignatureDate/
Qualifications for RegistrationImportant!If you believe that someone has interfered with your right to register or todecline to register to vote, your right to privacy in deciding whether to registeror in applying to register to vote, or your right to choose your own political partyor other political preference, you may file a complaint with:You Can Use This Form To: register to vote in New York State; change your name and/or address, if there is a changesince you last voted; enroll in a political party or change your enrollment.To Register You Must: be a U.S. citizen; be 18 years old by December 31 of the year in which you filethis form (note: You must be 18 years old by the date of thegeneral, primary, or other election in which you want to vote.); be a resident of the County, or of the City of New York at least30 days before an election; not be in jail or on parole for a felony conviction; and not claim the right to vote elsewhere.NYS Board of Elections 40 North Pearl St, Suite 5Albany, NY 12207-2729Telephone: 1-800-469-6872;TDD/TTY users contact the New York StateRelay at 711; or visit our web site www.elections.ny.govYour decision to register will remain confidential and will be used only for voterregistration purposes. Anyone not choosing to register to vote and/ or informationregarding the office to which the application was submitted will remainconfidential, to be used only for voter registration purposes.Verifying your identityWe will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver IDnumber), or the last four digits of your social security number, which you will fill in Box 9.If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement,paycheck, government check or some other government document that shows your name and address. You may include acopy of one of those types of ID with this form.If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.To complete this form:It is a crime to procure a false registration or to furnish false information to the Board of Elections.Box 9: You must make one selection. For questions refer to Verifying your identity above.Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?). If youvoted before under a different name, put down that name. If not, write “Same”.Box 11: Check one box only. Political party enrollment is optional but that, in order to vote in a primary election of a political party, avoter must enroll in that political party, unless state party rules allow otherwise.
APPLICATION FOR CHILD CARE ASSISTANCE ATTENTION: This application is used to apply ONLY for Category 2 or 3 Child Care Assistance. To apply for Cash Public Assistance or other benefits, including Category 1 Child Care Assistance, you must use the New York State Applicatio
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The Child Care Assistance Program (CCAP) helps income-eligible families pay for child care while they work or attend school or training. 6 Child Care Assistance Program Child Care Assistance Program 7 A relative residing in a separate home who is related to the child by .
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Care needed: (check all that apply) Child #1 Child #2 Child #3 Child #4 Child #5 Preferred Location (Zip Code other than home) Full day Part day Evenings Overnight Weekends Special Needs: Child #1 Child #2 Child #3 Child #4 Child #5 Limited English Child Protective Services Severely Handicapped
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